The Medicare Payment Advisory Commission, or MedPAC, should adopt recommendations to reflect the changing nature and locus of graduate medical education, or GME, as it relates to primary care. That's according to a comment letter submitted to MedPAC by the AAFP and other family physician organizations.
The groups, which include the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group, have asked MedPAC to adopt recommendations to change financial incentives that currently encourage teaching hospitals to confine their residents' learning experiences to hospitals. Under current law, hospitals cannot count residents as part of their residency load when they are sent out of the hospital to train in a nonhospital setting, which is where most family physician training takes place.
"Family medicine organizations have long proposed modernization of funding of graduate medical education for primary care production and training," say the organizations in the comment letter.
In the 1960s, when the program started, the decision to tie GME financing to inpatient hospital activity was logical because at that time it served as the locus of substantially all care delivery, according to the letter. During the past 45 years, however, this delivery mechanism and locus have changed considerably.
"This is particularly true for primary care which is delivered predominantly in outpatient, ambulatory, community-based office and other settings," says the letter. "Yet the obstacles preventing this training from taking place effectively are abundant."
The organizations also are calling on MedPAC to recommend a 5-year pilot program to evaluate modernized funding models for primary care training. Such a pilot could be budget neutral and would cost a fraction of the current allocation for GME, says the comment letter.
"Family medicine believes one concrete step toward accountability would be to publish an annual report of the total GME dollars received by each hospital and a requirement that each hospital report on the amount it has dedicated to primary care training and results obtained from that expenditure," says the letter.
The analysis should include measurement of the number of primary care physicians at the end of training rather than when a student enters the initial residency program. This would help ensure that the number of primary care physicians trained is recorded as the actual number of physicians who enter primary care practice, according to the organizations.
In the comment letter, the organizations stress their support for enhanced accountability for GME financing, saying that such accountability should be based on a thorough analysis of the existing and needed workforce. MedPAC should determine
- who benefits from physician training;
- if the beneficiaries of physician care should contribute to physician training through some mechanism;
- if funding is purposeful, predictable and stable;
- the size and specialty mix of physician workforce needed; and
- if current funding mechanisms and priorities lead to the desired workforce.